Anesthesia Coding Alert

Beginning in 2001, CMS (formerly HCFA) bundled ventilation-management (VM) codes with inpatient-care codes, which means Medicare carriers no longer view VM as a distinct service. It is considered part of the anesthesia service if it is performed as maintenance during a patient's surgical procedure. But there are circumstances outside the original procedure that allow billing it separately.

Ins and Outs of Ventilation-Management Codes

 
Two CPT codes apply to VM: 94656 (ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; first day) and 94657 (... subsequent days). An important point to keep in mind is that 94656 is for the initial placement of the vent, and not necessarily the first day a physician sees the patient.
 
"Some doctors attempt to bill 94656 when they see the patient for the first time, and they didn't place the patient on the ventilator originally," says Cecelia McWhorter, BA, CPC, a coder with the physician billing agency Comp One Services Ltd. in Oklahoma City. "The code is intended for the first day of vent management, period -- not a physician's first visit with the patient."
 
For example, an anesthesiologist places a patient on VM, a service coded as 94656. When he or she checks on the patient's status the next day, code that visit with 94657. Scott Groudine, MD, an Albany, N.Y., anesthesiologist, says the physician's notes and corresponding codes in this case might read:

 
June 12:

Called to intubate Mrs. Smith, who has just had a major myocardial infarction -- 31500 (intubation, endotracheal, emergency procedure).
   

A-line placed -- 36620 (arterial catheterization or cannulation for sampling, monitoring or transfusion [separate procedure];percutaneous).
   

Ventilator management for first day -- 94656; critical care provided by cardiologist.

June 13:

Ventilator adjusted; started weaning patient -- 94657.

 
June 14:

Patient weaned off ventilator -- 94657.

Vent Management Separate from E/M

 
Many carriers, such as Louisiana Medicare, have policies that state, "Payment for ventilation and management, CPT codes 94656 and 94657, includes evaluation and management service by the same physician on the same date. Visits on the same date are bundled into reimbursement for the ventilation-management service."
 
The exception is if the E/M service can be documented as significant and separately identifiable. For example, an anesthesia provider is called to assess a case of respiratory distress and treats the patient with inhalers and other respiratory therapy. Several hours later the respiratory distress worsens, and the provider intubates the patient and begins vent management. The patient is then transferred to ICU, where the anesthesiologist continues to oversee the vent-management care. 
 
For this scenario, use the appropriate E/M code for the initial visit, 99221-99223 (initial hospital care, per day, for the evaluation and management of a patient ...). To bill for both the E/M visit and the VM on the same day, you must append modifier -25 (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to the E/M code. Also be sure to include supporting documentation.
 
You must also provide an appropriate diagnosis that suggests a ventilator is needed, such as acute respiratory failure (518.81).
 
Once the patient is transferred to ICU, the anesthesiologist can usually only bill for VM, as described above, because critical care physicians are normally providing the primary care.
 
In another case, the anesthesiologist provides services during surgery. Then after surgery he or she is asked to assess the patient's level of respiratory distress in the PACU or ICU. You would most likely bill this scenario with the appropriate E/M code appended with modifier -59 (distinct procedural service), and the VM code to signify that the ventilator placement is separate from the initial procedure.
 
When billing the E/M services if the anesthesiologist spends more than 30 minutes with the patient within a 24-hour period (midnight to midnight), consider using the more accurate critical-care codes 99291 (critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and 99292 (... each additional 30 minutes) instead of automatically reporting the more general E/M codes. 
 
Vent Management and Critical Care

 
Ventilator management is usually not a covered service for routine postoperative ventilator patients (such as those recovering from coronary artery bypass graft surgery), even if they're in critical- or intensive-care units. Some patients might be put on a ventilator before being transferred from PACU to ICU for further care. Common reasons are they were not extubated after surgery (due to the extent of the procedure) or had significant blood loss or sepsis.
 
Many carriers, including Medicare carriers such as Empire New Jersey and Empire New York, say that vent codes 94656 and 94657 are bundled with critical-care codes for service by the same physician on the same date.
 
But, you can separately bill VM for a critical-care patient in certain cases, such as a hernia patient who needs postoperative ventilation because of an acute post-op lung or cardiac problem. In these cases, the critical-care codes (99291 and 99292) supercede any other applicable E/M codes for services that day.
 
"Anyone who is acutely ill on a ventilator should probably be in an ICU," Groudine says, "and the critical-care E/M codes are probably the better way to bill these services. This, of course, assumes that more is being done than just ventilator management."

 
Note: It's advisable to ask your private payers whether they allow VM to be billed separately or consider it bundled with other services.